Youth

Student's Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Name *

First Name

Last Name

Parent Cell Phone *

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I hereby release and agree to hold Harvest Lane Alliance Church harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of Harvest Lane Alliance Church, or that may otherwise arise in any way in connection with any services received from Harvest Lane Alliance Church. I understand that this release discharges Harvest Lane Alliance Church from any liability or claim that I, my heirs, or any personal representatives may have against the church with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Harvest Lane Alliance Church. This liability waiver and release extends to the Harvest Lane Alliance Church youth group (S.O.L.E.) together with all members and the chartering organization (Harvest Lane Alliance Church). *

I agree.

Student Name *

First Name

Last Name

Parent/Guardian Name *

First Name

Last Name

Parent Cell Phone *

(###)

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Emergency Contact Name *

First Name

Last Name

Emergency Contact Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Cell Phone *

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Harvest Lane Alliance Church, Liability Release and Consent to Travel: I, being an adult (of 18 years or older) or the parent/legal guardian of the minor named on the registration attached to this waiver, do hereby release Harvest Lane Alliance Church, its agents, assigns, employees, and volunteer assistants from any liability whatsoever arising out of injury, sickness, damage, or death, which may be sustained by myself or the above minor during any activity, trip, function, or the like-sponsored by or participated in by Harvest Lane Alliance Church, from September 2025 through September 2026. I also give my permission for the minor named on the registration attached to this waiver to attend and be transported to any activity, trip, function or the like sponsored by Harvest Lane Alliance Church, from September 2025 through September 2026 by a director or properly appointed adult sponsor of the student ministry of Harvest Lane Alliance Church. I, being an adult (of 18 years or older) or the parent/legal guardian of the minor named on the registration attached to this waiver, do hereby give my consent for the youth pastor or properly appointed adult sponsor of the student ministry Harvest Lane Alliance Church, to secure the administration of medical treatment or medication for the above named individual and do further agree to the performance of such treatment, anesthetic, and/or operations, as in the opinion of the attending physician is deemed necessary for myself or the above named minor while at any activity, trip, function, or the like sponsored by Harvest Lane Alliance Church, from September 2025 through September 2026. I have informed Harvest Lane Alliance Church, of all prescribed or over-the-counter medications that I or my minor are currently taking, all restrictions on medical treatment to be provided, of all allergies to medications and of special medical requirements by listing them on the portion of the form above. Parent/ Guardian/ Student 18 yrs, please check the box below. *

I agree to the terms.

I do not agree to the terms.

I, being an adult (of 18 years or older) or the parent/legal guardian of the minor named on the registration attached to this waiver, understand while I or the above named minor participates in any activity, trip, function or the like either sponsored by or participated in by Harvest Lane Alliance Church, from September 2025 through September 2026, I or the above named minor, is responsible to abide by the rules set forth by the sponsored organization, its leaders and/or all supervisory personnel. Any infraction of rules and/or conduct by the above named person(s), deemed to be serious by any director or properly appointed adult sponsor of the youth ministries of { Harvest Lane Alliance Church, can result in corrective action, up to and including dismissal from the event. In the event that I or the above named minor is dismissed from the program, I or the minor’s legal guardian agree to assume the entire cost of returning home, to forfeit any monies paid for the cost of the trip/event, and to assume responsibility for any monies owed for the cost of the trip/event. I or the above named minor fully understand and agree that there will be no refund of the cost of returning home. Parent/ Guardian/ Student 18 yrs, please check the box below. *

I agree to the terms.

I do not agree to the terms.